Physician practices related to use of BMI-for-age and counseling for childhood obesity prevention: a cross-sectional study

Evaluation of the relationship between insulin resistance and 8-iso prostaglandin levels in obesity children

INTRODUCTION

The rising rate of childhood obesity and the serious health problems it causes are gaining increasing attention in medical research and health policy.

Obesity screening in the pediatric emergency department - A missed opportunity?

Objectives

There is a low rate of body mass index measurements and obesity screening in primary pediatric care. Pediatric emergency department (PED) visits, with their large volumes and routine weight measurements, provide a unique opportunity to identify and address obesity. The study objectives were to examine the rate of addressing obesity in the PED and to identify its predicting factors.

Methods

From electronic medical records of PED visits during 2010-2019, we extracted data on age, gender, weight, time, listed diagnoses, and discharge texts. The primary outcome was a listed diagnosis of "obesity" on discharge letters of children with obesity. Secondary outcomes were addressing weight in the discharge letter and written recommendations for obesity-related treatment. Mixed models were used to test for associations between each of the three outcomes and patient/visit characteristics.

Results

There were 150,250 PED visits by 88,253 different children and adolescents. Obesity was found in 10,691 children (12.1%). Among these, listed "obesity" diagnosis was present in only 240 (1.5%) visits. Text addressing overweight/obesity was recorded in 721 (4.4%) visits, and weight-related recommendations were documented in 716 (4.4%) visits. "Obesity" was documented in females more often than in males, in older children, in children with higher weights, and in visits conducted during the mornings.

Conclusions

The rate of obesity diagnosis in the PED was extremely low, hence the potential screening ability of the PED in this matter is highly under-utilized. PEDs could increase the recognition of obesity, thus assisting in the global efforts in tackling this disease.

Barriers and facilitators to implementing practices for prevention of childhood obesity in primary care: A mixed methods systematic review

Primary care providers (PCPs) have an important role in prevention of excess weight gain in pre-school children. Guidelines exist to support PCPs' practices. This systematic review of PCPs' practice behaviors and their perceptions of barriers to and facilitators of implementation of guidelines was the first step toward the development of an intervention aimed at supporting PCPs. Five databases were searched to identify qualitative, quantitative, and mixed methods studies which examined PCPs' practice patterns and factors influencing implementation of recommended practices. The convergent integrated approach of the Joanna Briggs Institute (JBI) methodology for mixed methods reviews was used for data synthesis. Following analyses, the resultant factors were mapped onto the Capability, Opportunity, and Motivation model of Behaviour (COM-B). Fifty studies met the eligibility criteria. PCPs inconsistently implement recommended practices. Barriers and facilitators were identified at the provider (e.g., lack of knowledge), parent (e.g., lack motivation), and organization level (e.g., inadequate training). Factors were mapped to all three components of the COM-B model: psychological capability (e.g., lack of skills), reflective motivation (e.g., beliefs about guidelines), automatic motivation (e.g., discomfort), physical opportunity (e.g., time constraints), and social opportunity (e.g., stigma). These findings reflect the complexity of implementation of childhood obesity prevention practices.

Effectiveness of a Primary Care-Based Pediatric Weight Management Program

BACKGROUND

Childhood obesity is a growing epidemic of great concern for our nation, including pediatric populations treated at military treatment facilities.

OBJECTIVE

This study aims to retrospectively evaluate the effectiveness of a primary care-based structured weight management program in a sample of pediatric patients with obesity at a military treatment facility.

METHODS

This study was a retrospective chart review of patients enrolled in the All About Me Program (AAMP) from August 1, 2011, through July 10, 2012. Baseline demographics, 5-2-1-0 behavioral targets, and anthropometric measures were obtained from 54 enrollees. Pre- and post-program weight, body mass index (BMI) percentile, and 5-2-1-0 behavioral targets were compared for 20 patients who completed the program which consisted of a total of five visits over 3 months.

RESULTS

Participants showed a significant reduction in their BMI, improvement in daily servings of fruits and vegetables, reduction in recreational screen time from baseline, improvement in daily physical activity, and reduction in consumption of sugary beverages.

CONCLUSIONS

These preliminary findings are a promising indicator that primary care-based obesity interventions may be effective for the management and treatment of pediatric obesity.

IMPLICATIONS FOR NURSING

This evidence-based toolkit provides a practical point-of-care guidance on the prevention, assessment, and treatment of childhood obesity and can be easily implemented in other primary care settings.

US Pediatrician Practices on Early Nutrition, Feeding, and Growth

OBJECTIVE

Assess pediatrician practices around growth and nutrition for children under 2 years.

DESIGN

2017 cross-sectional survey of a national random sample of the American Academy of Pediatrics members.

SETTING

US.

PARTICIPANTS

Practicing primary care pediatricians and residents (n = 698).

MAIN OUTCOME MEASURES

World Health Organization growth chart use, solid food introduction recommendations, healthy behaviors discussion.

ANALYSIS

Descriptive statistics were calculated for nutrition-related questions. McNemar tests compared recommendations on the introduction of different solid foods at <6 months; chi-square tests of independence examined outcomes by pediatrician and practice characteristics.

RESULTS

Most respondents (82.2%) reported using the World Health Organization growth charts at all well visits. Nearly half (45.3%) recommended solid food introduction at 6 months; 48.2% recommended <6 months. Cereals were more frequently recommended at <6 months than fruits/vegetables or meats (P <.001). Topics most frequently discussed were limiting juice (92.3%), and sugar-sweetened beverages (92.0%), avoiding restrictive and permissive food practices (30.7%), and avoiding food as a reward (29.1%) were least discussed. Pediatricians in hospital/clinic settings discussed healthy behaviors less than group or solo/2-physician practices.

CONCLUSIONS AND IMPLICATIONS

For children under 2 years, most pediatricians reported using recommended growth charts and discussing healthy behaviors. Fewer discussed responsive feeding topics. Results for guiding solid food introduction were mixed. Continued efforts to support pediatricians' work could improve the implementation of recommended practices.

Identifying obesity/overweight status in children and adolescents; A cross-sectional medical record review of physicians' weight screening practice in outpatient clinics, Saudi Arabia

BACKGROUND

BMI is a feasible and recommended measure for overweight and obesity screening in children and adolescents. The study aimed to determine how often physicians correctly identified obesity/ overweight status in children and adolescents by using BMI percentile charts.

METHODS

This retrospective cross-sectional study reviewed the paper medical records of children and adolescents (6-14 years) who visited family medicine and pediatric outpatient clinics (Jan-June 2012) in a medical city in Riyadh. Investigators calculated BMI percentiles (using height, weight, age and gender data retrieved from the records) in order to identify patient weight status. Physician documentation of obesity/overweight diagnoses in patient problem lists were cross checked against their BMI percentile to assess the accuracy of physicians' identification of weight status. The recommended management plan for identified patients was also recorded.

RESULTS

A total of 481 charts were reviewed, 213 (44%) children were seen by family medicine physicians and 268 (56%) by pediatricians. The sample was equally distributed by gender. Height was undocumented for 13% (71) of visiting patients. Eighteen percent of patients (86) were classified as overweight (35)/obese (51) according to age and sex adjusted BMI percentile. Physicians' correctly identified and documented weight status in 20% of overweight/obese patients: 17 out of 86 subjects. Weight status identification was higher among pediatricians-25% as compared to family medicine physicians-10% [p = 0.08]. Dietary referral was the most common management plan for the identified children. Physicians were more likely to identify obese children {≥95th} compared to overweight {≥85th - 95th} children. Subjects whose BMI for age classified them into the highest BMI percentile category {≥95th} were more likely to be correctly identified (29%) compared to those classified within {≥85th - 95th} category-6% [p = 0.007].

CONCLUSION

Physician identification of obesity/ overweight status for children and adolescents was low, irrespective of their specialty, and despite the condition being prevalent in the sample. Future research that concentrates on interventions that may improve documentation of obesity/overweight diagnoses and parameters needed for BMI indices would be beneficial.

Identification of Overweight and Obesity in Low-Income Minority Children by Pediatric Providers and Child Characteristics Associated With Underrecognition

INTRODUCTION

Childhood overweight and obesity remains prevalent. We sought to identify characteristics associated with correct coding of obese and overweight children ages 2-9 years by pediatric primary care providers (PCPs) in an urban, minority clinic.

METHOD

Samples included electronic health records pre- (n = 262) and post- (n = 244) provider training to implement an intervention aiming to improve consistency in obesity prevention and management guidelines from 15 providers. Analysis included descriptive statistics and simple logistic regression.

RESULTS

Child characteristics consistently associated with correct coding in both pre- and post-intervention included children with obese body mass index percentiles (vs. overweight) and older-aged children (vs. toddlers). Provider characteristics were not associated.

DISCUSSION

Improvements in coding overweight and obese children occurred post-intervention, yet many were missed. Knowledge of characteristics associated with missed coding can inform targeted training for PCPs to implement evidence-based obesity guidelines with full fidelity for all families.

Physician Characteristics Associated With Sugar-Sweetened Beverage Counseling Practices

PURPOSE

Frequent sugar-sweetened beverage (SSB) consumption is associated with chronic disease. Although physician counseling can positively affect patient behavior, physicians' personal characteristics may influence counseling practices. We explored SSB-related topics physicians discuss when counseling overweight/obese patients and examined associations between physicians' SSB-related counseling practices and their personal and medical practice characteristics.

DESIGN

Cross-sectional survey.

SETTING

DocStyles survey, 2014.

PARTICIPANTS

A total of 1510 practicing US physicians.

MEASURES

Physician's SSB counseling on calories, added sugars, obesity/weight gain, health effects, consumption frequency, water substitution, and referral.

ANALYSIS

Adjusted odds ratios (aORs) were calculated with multivariable logistic regression, adjusting for physician's personal and medical practice characteristics.

RESULTS

Most physicians (98.5%) reported SSB-related counseling. The most reported topic was obesity/weight gain (81.4%); the least reported were added sugars (53.1%) and referral (35.0%). Physicians in adult-focused specialties had lower odds than pediatricians of counseling on several topics (aOR range: 0.26-0.64). Outpatient physicians had higher odds than inpatient physicians of counseling on consumption frequency and water substitution (aOR range: 1.60-2.01). Physicians consuming SSBs ≥1 time/day (15.7%) had lower odds than nonconsumers of counseling on most topics (aOR range: 0.58-0.68).

CONCLUSION

Most physicians reported SSB-related counseling; obesity/weight gain was discussed most frequently. Counseling opportunities remain in other topic areas. Opportunities also exist to strengthen SSB counseling practices in adult-focused specialties, inpatient settings, and among physicians who consume SSBs daily.

Modifying Provider Practice To Improve Assessment of Unhealthy Weight and Lifestyle in Young Children: Translating Evidence in a Quality Improvement Initiative for At-Risk Children

BACKGROUND

We designed a quality improvement (QI) project to address the high prevalence of childhood overweight and obesity (OW/OB) in our patient population and the inconsistencies among primary care providers in recognizing and addressing OW/OB.

METHODS

We used mixed methods data collection approach to evaluate a QI project, the Childhood Healthy Behaviors Intervention (CHBI), to improve provider obesity prevention practice in two low-income, predominantly African American pediatric primary care clinics. Electronic record data were extracted from all 2-9 year well visits pre- and postintervention for frequency of appropriate diagnostic coding of OW/OB. We reviewed a random sample of records for details of health habit assessment and counseling documentation. Focused interviews were conducted to elicit provider responses regarding impressions of the intervention.

RESULTS

The preintervention sample of records (n = 267) was extracted from 18 providers and the postsample (n = 253) from 19 providers. Providers showed improvement in the recognition of OW/OB with appropriate diagnostic coding (52% pre, 68% post), improvement in assessment of health habits informed by the habit survey (0% pre, 76% post), improvement in counseling of healthy behaviors (86% pre, 92% post), and improvement in goal setting of healthy behaviors (12% pre, 70% post).

CONCLUSIONS

Our findings suggest that implementing a time efficient primary care intervention with brief provider training can improve provider recognition of OW/OB, as well as improve provider behavior targeted at childhood obesity prevention. This project contributes needed QI evidence on interventions to prevent and address OW/OB in primary care settings and calls for further work to strengthen implementation in similar contexts.

Validity of a simplified screening instrument for assessing overweight children in a dental setting: a cross sectional study

Background

Obesity, with its rising prevalence among Canadians and its estimated cost of $2 billion annually in Canada, is no longer considered a cosmetic issue, but a major health issue that imposes a great burden on the healthcare system and economy. This cross sectional study aims to evaluate the feasibility of identifying the weight status of 6 to 11 year-old children in a university dental clinic using a simplified overweight screening instrument.

Methods

One hundred sixty eight healthy children were enrolled. Weight and height were measured and overweight/obesity status was assessed using two techniques: 1) the 2007 World Health Organization Body Mass Index (BMI)-for-age reference Tables, 2) simplified overweight screening instrument without BMI calculation. Measures of overall, positive, and negative percent agreement between the two approaches were computed.

Results

The children’s average weight, height, BMI and BMI z-score were respectively 32.6 ± 9.5 kg, 133.8 ± 10.7 cm, 17.8 ± 3.2, and 0.4 ± 1.0. The overall, positive, and negative percent agreement between the two screening approaches were respectively, 89%, 100%, and 83%.

Conclusion

This study demonstrated the feasibility and parental acceptance of weight, height and BMI measurement in a dental setting and evidence that supports the validity of a new simplified approach to assess children’s weight status without having to compute BMI.

Trial registration

NCT02637752. Registered 18 December 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0808-x) contains supplementary material, which is available to authorized users.

Using weight-for-age percentiles to screen for overweight and obese children and adolescents

There are relatively low rates of screening for overweight and obesity among children and adolescents in primary care. A simplified method for such screening is needed. The study objective was to examine if weight-for-age percentiles are sufficiently sensitive in identifying overweight and obesity in children and adolescents. We used data from two distinct sources: four consecutive cycles of the National Health and Nutrition Examination Surveys (NHANES) from the years 2005 to 2012, using participants aged 2-17.9 years for whom data on age, sex, weight, and height were available (n=12,884), and primary care clinic measurements (n=15,152). Primary outcomes were the threshold values of weight-for-age percentiles which best discriminated between normal weight, overweight, and obesity status. Receiver operating characteristic analyses demonstrated that weight-for-age percentiles well discriminated between normal weight and overweight and between non-obese and obese individuals (area under curve=0.956 and 0.977, respectively, both p<0.001). Following Classification and Regression Trees analysis, the 90th and 75th weight-for-age percentiles were chosen as appropriate cutoffs for obesity and overweight, respectively. These cutoffs had high sensitivity and negative predictive value in identifying obese participants (94.3% and 98.6%, respectively, for the 90th percentile) and in identifying overweight participants (93.2% and 95.9%, respectively, for the 75th percentile). The sensitivities and specificities were nearly identical across race and sex, and in the validation data from NHANES 2011 to 2012 and primary care. We conclude that weight-for-age percentiles can discriminate between normal weight, overweight and obese children, and adolescents. The 75th and 90th weight-for-age percentiles correspond well with the BMI cutoffs for pediatric overweight and obesity, respectively.

Pilot Study of a Computer-Based Parental Questionnaire and Visual Profile of Obesity Risk in Healthy Preschoolers

PURPOSE

This group field-tested a computer-based, parental questionnaire entitled the Childhood Obesity Risk Questionnaire 2-5 (CORQ 2-5) designed to assess obesity risk in healthy preschoolers. COR 2-5 generates a profile of seven obesity risk factors.

RESULTS

Field studies provided good internal reliability data and evidence of discriminant validity for the CORQ 2-5. Pediatric nurse clinicians found the CORQ 2-5 profile to be clinically relevant.

CONCLUSION

The CORQ 2-5 is a promising measure of obesity risk in preschoolers who attend community-based health centers for their wellchild visits and who are not yet obese. CORQ 2-5 is intended to guide provider-parental obesity risk discussions.

The development and effectiveness of a health information website designed to improve parents' self-efficacy in managing risk for obesity in preschoolers

PURPOSE

To evaluate the effects of web-based information on parental self-efficacy in managing obesity risk in preschoolers.

DESIGN AND METHODS

The project included a literature review and the development and field testing of an information website that presented information on how to manage nine obesity risk factors for childhood obesity.

RESULTS

Parents stated that they had no problems using the website, and 69% reported improved self-efficacy on at least two risk factors.

PRACTICE IMPLICATIONS

Many parents access the Internet to obtain health information. A website that offers practical information on managing childhood obesity risk factors is a valuable resource for obesity prevention efforts.

Initial steps for quality improvement of obesity care across divisions at a tertiary care pediatric hospital

Background: Pediatric subspecialists can participate in the care of obese children. Objective: To describe steps to help subspecialty providers initiate quality improvement efforts in obesity care. Methods: An anonymous patient data download, provider surveys and interviews assessed subspecialty providers’ identification and perspectives of childhood obesity and gathered information on perceived roles and care strategies. Participating divisions received summary analyses of quantitative and qualitative data and met with study leaders to develop visions for division/service-specific care improvement. Results: Among 13 divisions/services, subspecialists’ perceived role varied by specialty; many expressed the need for cross-collaboration. All survey informants agreed that identification was the first step, and expressed interest in obtaining additional resources to improve care. Conclusions: Subspecialists were interested in improving the quality and coordination of obesity care for patients across our tertiary care setting. Developing quality improvement projects to achieve greater pediatric obesity care goals starts with engagement of providers toward better identifying and managing childhood obesity.

Cardiometabolic risk assessments by body mass index z-score or waist-to-height ratio in a multiethnic sample of sixth-graders

Convention defines pediatric adiposity by the body mass index z-score (BMIz) referenced to normative growth charts. Waist-to-height ratio (WHtR) does not depend on sex-and-age references. In the HEALTHY Study enrollment sample, we compared BMIz with WHtR for ability to identify adverse cardiometabolic risk. Among 5,482 sixth-grade students from 42 middle schools, we estimated explanatory variations (R²) and standardized beta coefficients of BMIz or WHtR for cardiometabolic risk factors: insulin resistance (HOMA-IR), lipids, blood pressures, and glucose. For each risk outcome variable, we prepared adjusted regression models for four subpopulations stratified by sex and high versus lower fatness. For HOMA-IR, R² attributed to BMIz or WHtR was 19%–28% among high-fatness and 8%–13% among lower-fatness students. R² for lipid variables was 4%–9% among high-fatness and 2%–7% among lower-fatness students. In the lower-fatness subpopulations, the standardized coefficients for total cholesterol/HDL cholesterol and triglycerides tended to be weaker for BMIz (0.13–0.20) than for WHtR (0.17–0.28). Among high-fatness students, BMIz and WHtR correlated with blood pressures for Hispanics and whites, but not black boys (systolic) or girls (systolic and diastolic). In 11-12 year olds, assessments by WHtR can provide cardiometabolic risk estimates similar to conventional BMIz without requiring reference to a normative growth chart.

Using motivational interviewing for weight feedback to parents of young children

AIM

To determine whether a single session of motivational interviewing (MI) for feedback of a child's overweight status promotes engagement in treatment following screening.

METHODS

One thousand ninety-three children aged 4-8 years were recruited through primary and secondary care to attend health screening, including assessment of parenting practices and motivation (questionnaire). Families with normal-weight children were informed about their child's weight but had no further involvement. Parents of overweight (body mass index ≥ 85th percentile) children (n = 271) were randomised to receive weight feedback via MI or best practice care (BPC) using a traffic light concept to indicate degree of health risk. Follow-up interviews were held 2 weeks later to examine intervention uptake, changes to motivation and behaviour, and parental response to feedback.

RESULTS

Recruitment into the intervention was high (76%) and not altered by feedback condition (percentage difference 6.6 (95% confidence interval -2.9, 16.0). High scores on the Health Care Climate Questionnaire (rating of the interviewer) indicated satisfaction with how the information was provided to parents. No differences were observed in multiple indicators of harm. However, self-determined motivation for healthy life-styles was significantly higher in the MI condition at follow-up (0.18: 0.00, 0.35), after only a single session of MI.

CONCLUSIONS

MI and BPC were both successful in encouraging parents to participate in a family-based intervention, with MI offering little significant benefit over BPC. A traffic light approach to weight feedback is a suitable way of providing sensitive information to parents not expecting such news.

Characteristics of US Health Care Providers Who Counsel Adolescents on Sports and Energy Drink Consumption

Objective. To examine the proportion of health care providers who counsel adolescent patients on sports and energy drink (SED) consumption and the association with provider characteristics. Methods. This is a cross-sectional analysis of a survey of providers who see patients ≤17 years old. The proportion providing regular counseling on sports drinks (SDs), energy drinks (EDs), or both was assessed. Chi-square analyses examined differences in counseling based on provider characteristics. Multivariate logistic regression calculated adjusted odds ratios (aOR) for characteristics independently associated with SED counseling. Results. Overall, 34% of health care providers regularly counseled on both SEDs, with 41% regularly counseling on SDs and 55% regularly counseling on EDs. On adjusted modeling regular SED counseling was associated with the female sex (aOR: 1.44 [95% CI: 1.07–1.93]), high fruit/vegetable intake (aOR: 2.05 [95% CI: 1.54–2.73]), family/general practitioners (aOR: 0.58 [95% CI: 0.41–0.82]) and internists (aOR: 0.37 [95% CI: 0.20–0.70]) versus pediatricians, and group versus individual practices (aOR: 0.59 [95% CI: 0.42–0.84]). Modeling for SD- and ED-specific counseling found similar associations with provider characteristics. Conclusion. The prevalence of regular SED counseling is low overall and varies. Provider education on the significance of SED counseling and consumption is important.

Childhood obesity in secondary care: national prospective audit of Australian pediatric practice

OBJECTIVE

In many countries, pediatricians offer skilled secondary care for children with conditions more challenging than can readily be managed in the primary care sector, but the extent to which this sector engages with the detection and management of obesity remains largely unexplored. This study aimed to audit the prevalence, diagnosis, patient, and consultation characteristics of obesity in Australian pediatric practices.

METHODS

This was a national prospective patient audit in Australia. During the course of 2 weeks, members of the Australian Paediatric Research Network prospectively recorded consecutive outpatient consultations by using a brief standardized data collection form. Measures included height, weight, demographics, child and parent health ratings, diagnoses, referrals, investigations, and consultation characteristics. We compared the prevalence of pediatrician-diagnosed and measured obesity (body mass index ≥95th percentile) and top-ranked diagnoses, patient, and consultation characteristics in (a) obese and nonobese children, and (b) obese children with and without a diagnosis.

RESULTS

A total of 198 pediatricians recorded 5466 consultations with 2-17 year olds, with body mass index z-scores calculated for 3436 (62.9%). Of the 12.6% obese children, only one-third received an "overweight/obese" diagnosis. Obese children diagnosed as overweight/obese were heavier, older, and in poorer health than those not diagnosed and incurred more Medicare (government-funded health system) cost and referrals.

CONCLUSIONS

Obesity is infrequently clinically diagnosed by Australian pediatricians and measurement practices vary widely. Further research could focus on supporting and normalizing clinical obesity activities from which pediatricians and parents could see clear benefits.

Barriers to successful recruitment of parents of overweight children for an obesity prevention intervention: a qualitative study among youth health care professionals

BACKGROUND

The recruitment of participants for childhood overweight and obesity prevention interventions can be challenging. The goal of this study was to identify barriers that Dutch youth health care (YHC) professionals perceive when referring parents of overweight children to an obesity prevention intervention.

METHODS

Sixteen YHC professionals (nurses, physicians and management staff) from eleven child health clinics participated in semi-structured interviews. An intervention implementation model was used as the framework for conducting, analyzing and interpreting the interviews.

RESULTS

All YHC professionals were concerned about childhood obesity and perceived prevention of overweight and obesity as an important task of the YHC organization. In terms of frequency and perceived impact, the most important impeding factors for referring parents of overweight children to an intervention were denial of the overweight problem by parents and their resistance towards discussing weight issues. A few YHC professionals indicated that their communication skills in discussing weight issues could be improved, and some professionals mentioned that they had low self-efficacy in raising this topic.

CONCLUSIONS

We consider it important that YHC professionals receive more training to increase their self-efficacy and skills in motivating parents of overweight children to participate in obesity prevention interventions. Furthermore, parental awareness towards their child's overweight should be addressed in future studies.